Weisman & Simpson (2007)

THE PSYCHOLEGAL IMPLICATIONS OF BRAIN TRAUMA

A CASE OF EPISODIC DYSCONTROL AND CENTRAL BRAIN TRAUMA

Adam M. Weisman, Ph.D. & Joseph R. Simpson, MD, PhDUSC Institute of Psychiatry, Law and Behavioral Science

Weisman & Simpson (2007)

Introduction

• Common forensic examinations• Domestic violence: relationship-based• Episodic dyscontrol: unprovoked & odd

• Common psycho-legal issues• Diagnostic considerations: linked to

causation• Static variables: constitutional traits• Dynamic variables: situational (e.g., medical)

• Risk of danger to victim/community• Dispositional recommendations

Weisman & Simpson (2007)

Introduction

• Overt neurological condition: effective total defense strategy• E.g., post-concussion, post-stroke, seizures,

dementia • Covert neurological condition: difficult to use

for complete defense in violence• Appears normal apart from nonspecific symptoms

(nausea, headaches or dizziness)• Mitigation strategy (charge or sentence reduction)

• Case presentation: covert neurological condition presented as defense for violent act

Weisman & Simpson (2007)

Case of Ms. P.

• 21-year-old, single, employed, African-American female

• Charge: two counts assault with deadly weapon (knife)

• Victims: ex-boyfriend & ex-boyfriend’s girlfriend

• 10/26/05: offense date

Weisman & Simpson (2007)

Background Information

• Born in Los Angeles County; parents never married; mother in drug rehabilitation, father killed 1992 from hit-and-run vehicle accident

• 2nd child with 1 brother, 2 sisters, 5 paternal half brothers & 6 paternal half sisters

• Criminal history: mother-commercial burglary, sister-check fraud

• Substance use history: parents-cocaine• Mental illness history: sister-bipolar illness• Abuse/neglect: raised by aunt due to mother’s substance

use; molestation by adult preteen years without report

Weisman & Simpson (2007)

Background History

• Education: high school graduate• Work: data entry clerk with

temporary agencies• Substance use history: casual

alcohol use• Criminal history: none• Psychiatric history: none

Weisman & Simpson (2007)

Background History

• Psychosexual history• Sexual activity: initiated at age 18 with

victim• Victim: Jamaican alien, 37, married• Relationship: 2.75 years• Defendant and victim’s spouse aware of

extramarital relationship• Defendant unaware of intimacy between

boyfriend and victim #2• Drastic change in relationship: 9/23/05

Weisman & Simpson (2007)

Medical History

• Summer of 2004 (age 19) developed severe headaches

• CT scan showed pituitary mass

• Headaches resolved, no follow-up for several months

• In early 2005 headaches returned and she developed galactorrhea

Weisman & Simpson (2007)

Medical History

• Prolactin level 181 ng/ml in Feb. 2005

• MRI in March 2005 showed 2 cm pituitary adenoma with hemorrhage

Weisman & Simpson (2007)

T1-weighted, non-contrastMagnetic Resonance Image

Weisman & Simpson (2007)

Medical History

• Treated with dopamine agonist (Dostinex® (cabergoline))

• Over next several months adenoma shrunk by roughly half as seen on repeat MRI in late August 2005• Prolactin level had also normalized

• She elected surgery to remove the adenoma

Weisman & Simpson (2007)

Medical History

• Underwent transsphenoidal resection of the adenoma in Sept. 2005, just over one month prior to the instant offense

Weisman & Simpson (2007)

Neuropsychiatric complications common with pituitary tumors

• Neuropsychiatric manifestations are common in CNS tumors.

• Behavioral symptomatology reported in as much as 60% of cases of pituitary tumors.

• Disturbances include mood, anxiety and psychotic symptoms and cognitive impairment.• Price TRP. Neuropsychiatric Aspects of Brain Tumors. In:

Sadock BJ and Sadock VA eds. Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 8th ed. Philadelphia: Lippincott Williams and Wilkins; 2005: 361-377

• Wilcox JA, Naranjo J. Psychiatric manifestations of pituitary tumors. Psychosomatics. 1997 Jul-Aug;38(4):396-7.

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Neuropsychiatric complications of tumor resection

• In some cases, surgical treatment of adenomas can lead to cognitive or psychiatric sequelae.• Guinan EM, Lowy C, Stanhope N, Lewis PD, Kopelman MD.

Cognitive effects of pituitary tumours and their treatments: two case studies and an investigation of 90 patients. Journal of Neurology & Neurosurgurical Psychiatry. 1998 Dec;65(6):870-6.

• Peace KA, Orme SM, Padayatty SJ, Godfrey HP, Belchetz PE. Cognitive dysfunction in patients with pituitary tumour who have been treated with transfrontal or transsphenoidal surgery or medication. Clinical Endocrinology (Oxford). 1998 Sep;49(3):391-6.

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Disposition

• 2/4/06: Forensic report for defense• 4/28/06: plead no contest to charges; one count

dismissed• Suspended sentence on formal probation; 180

days credit time; $998 restitution to victim #2• Approximately 15 months after the instant offense

• No further episodes of aggression or impulsivity; resumed temporary clerical duties

• No clear evidence of neuropsychiatric dysfunction on clinical interview or neuropsychological screening tests

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Conclusion

• Forensic evaluations should always include a thorough medical history

• Pre- and Post-surgery involving CNS system may influence the management of prosocial behavior

• Presentation of hypotheses involving covert neurological condition may influence legal parties in terms of mitigation